HomeMy WebLinkAboutLa Mesa food truck - 12/31/2021I
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FOR BOARD OF HEALTH USE ONLY
Date (R�e'ceIiv�ed` Permit Fee Approved By Permi Issued
Mobile Food Establishment (MFE) Permit Application
(Application must be submitted at least 14 business days before the planned opening date)
1) MFE Name: La—
2) ApplicantlOwner Name & Title:
Applicant(Owner Address:
ApplicantlOwner Telephone No:
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ApplicantlOwner Email address: AIVP fe?, Q
3) Person In Charge of Onsite Operations & Title:
PIC Address: VQ,lxx av ae—
PIC Telephone No:
Emergency/onsite Telephone No:
PIC Email Address:
4) Location of Service:
Date(s) if applicable:
Event Name if applicable:
Event/ Service Location:
Everitt Service time:
6) Length of Pe it:
6) Solid waste disposal plan,
Annual
L7UMmo.(rCT'�� ni�e-�617
o Temporary
Dates:
7) Water Source:
6) Sewage disposal plan:
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9) Food will be prep red:
o Onsite for immediate consumption
o qnsite and held at proper hot/ cold holding temperatures
Offsite and held at proper hot/ cold holding temperatures
/` Offsite, cooled and reheated on site
0 other:
10) Please attach a/menu or a website linkto the menu or give a brief description of the food to be served:
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11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety Manage(
Allergen Awareness:�lO�t�t.`--
12) Plea a dose ibe on sit hand washing facilities that will be utilized:
13) Please list all sanitizipg solutions that will be on site:
14) Do you have propane, fryolators andlor hoods on your truck?
If yes, you must first be inspected and approved by the Mansfield 4re Department. Phone number: 608-261.7321
Fire Department Signature of Approval:
16) If applicable, please describe your FOG management plan or attach the written plan:
16) Location of Base of Operations or Commissary:
Please attach copies of Base of Operations or Commissary Permit.
17) Please 1sto Iti al com unities wherreeja food permit is held:
✓.✓/ �(? �
I, the undersigned, attest to the accuracy of the information provided In this application and I affirm that the food
establishment operation will comply with 105 CMR 590.00,q and all other applicable law. I have been instructed by
the board of health on how to obtai P of 106 0.0001 and a fe eral Food Code.
18)SlgnatureofApplicant:
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all state tax returns and paid state taxes required under law.
19) Social Security Number or Federal ID:
_ oA
20) SignatureofIndividual orCorporateName: ____
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
�I
SignatureAf Individual or Corporate Name
P/7/
*"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:WsenWefleWesktoplScotrs DocumentsTood Establishments- Temp1TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Analicant Information Please Print Legibly
Business/Organization
Phone #:
Are you an employer? Check the appropriate box:
].❑ I am a employer with employees (full and/
or part-time).*
2. I am a sole proprietor or partnership and have no
e loyees working for me in any capacity.
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, §1(4), and we have
no employees. [No workers' comp, insurance required]'
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
,3,Y� % C�
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
1 I,❑ Health Care / — /
12.❑Other /LGoY1,xc 7eOo n/ I�Pld4)
*Any applicant that checks box kl must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box N 1. -
I am an employer that Is providing workers' compensation Insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic.
Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I rlo hereby Sertlfy, under the Pons and penaNes of perjury that Ure information provided above is true�and correct.
Official use only. Do not write In this area, to he completed by city or town official.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
Phone
www.mass.gov/dia
TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
Gba(gs�tp�}J�ustomers.
AV_ "ve received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines.
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared food and drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostable
alternatives. Compostable materials must meet ASTM (American Society of the International Association
Aspon
gand Materials) Standards for compostability.
have received a copy of the Polystyrene Container Reduction bylaw. I understand my
ility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction with the serving by business establishments or at any town -sponsored event of liquid,
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frozenforms of beverages to the public for consumption.
ived a e Plastic Straw/Stirrer Reduction bylaw. I understand my
ure thaw is adhered to at the permitted food establishment. I understand
law will result in fines.
Applicant
Applicant
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www,mass.gov/dia
rem Revised 5-26-05
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Burritos: Slowly Braised Barbacoa, Grilled Chicken,
Veggie
savory yellow vegan rice, slowly stewed vegan pinto beans,
fresh guacamole, zesty pico, shredded lettuce and monterey
cheese
and our own fresh salsa verde.
Quesadillas: Slowly Braised Barbacoa, Grilled Chicken,
Veggie
molten monterey cheese, roasted fresh corn, seasoned black
beans,
grilled peppers and onions and our own chipotle sauce.
Fish Tacos: deep fried cod,
cabbage, pickled red onions, zesty pico, creamy avocado,
sweet mango, and our own chipotle sauce
Empanadas: 1. spicy beef 2.black bean & sweet plantain
handmade flaky crispy pastry, filled with savory ingredients.
Chips and Fresh Salsa served with every meal
Drinks: soft drinks, water
Amy Donovan -Palmer
From: Alba Garay <lamesafoodtruck@gmail.com>
Sent: Friday, July 23, 2021 12:18 PM
To: Amy Donovan -Palmer
Subject: Fwd: Fw: Health department permit
Hello again Amy,
Hands on Hartford has yet to receive their new license. Please see below
---------- Forwarded message ---------
From: Alba Garay <lamesafoodtruck@vahoo.com>
Date: Fri, Jul 23, 2021 at 12:12 PM
Subject: Fw: Health department permit
To: Alba Garay <lamesafoodtruck@amail.com>
Sent from Yahoo Mail for iPhone
Begin forwarded message:
On Friday, July 23, 2021, 12:10 PM, Reynolds, Molly <mreynolds@handsonhartford.org> wrote:
Hi Alba,
We haven't received a new license from the City of Hartford yet. It usually takes a few months
after the old one expires. Sorry about that.
Molly Reynolds
Special Projects Coordinator
Hands On Hartford
55 Bartholomew Avenue
Hartford, CT 06106
Direct - 860.706A537
Main 860.728.3201 x 1537
F 860.549.8550
E mreynolds@handsonhartford.org
years changing lives
Hands";Wn
Canna m Activ, HARTFORD
Honoring our legacy, strengthening our commitment
This email may contain confidential and privileged material for the sole use of the intended recipient(s).
Any review, use, retention, distribution or disclosure by others is strictly prohibited.
If you are not the intended recipient (or authorized to receive for the recipient),
please contact the sender by reply email and delete all copies of this message.
From: Alba Garay <lamesafoodtruck@vahoo.com>
Sent: Friday, July 23, 2021 11:45 AM
To: Reynolds, Molly <mreynolds@handsonhartford.ore>
Subject: Health department permit
Good morning Molly, can I please get a copy of the health department permit for the kitchen?
Sent from Yahoo Mail for Whone